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Paineurope: Issue 4, 2004. Brief Notes:

December 22, 2009 | Filed Under: Latest Readings | Comments(0)
  • Researchers at University College London used functional MRI (fMRI) to understand how humans learn to predict conditions that lead to aversive stimulation and pain. Subjects were presented with a series of abstract pictures followed by a 1 second electric shock. While they could not recall the sequence of the images, the imaging indicated that volunteers had learned how to predict the pain-producing conditions. The study concludes that: “The subconscious interpretation of environmental cues, leading to the avoidance of aversive stimuli, may be to the disadvantage (sic) of the persistent pain sufferer.” Dr. Adams Implications: The study conclusions are the just the opposite of what commonsense and casual observation indicate has survival value for any living organism. That is, the ability of lliving organisms to learn to avoid, escpae or terminate the conditions of pain’s occurrence, by effectively modifying the conditions of its occurrence. Clearly this ability provides evolutionary advantage rather than disadvantage to the living organism that learns to manipulate its environment to terminate aversive stimulation. The critical application of this evolutionary skill for CNCP patients is that the ability to effectively escape, avoid or terminate aversive stimulation, technically, is a positive reinforcer and, biochemically, that means systematic release of endorphins. In our program, CNCP patients learn how to avoid aversive stimulation, reinstate release of endorphins, and thereby, as endorphin release is returned to steady state (pre-injury) levels, systematically reduce pain long term.
  • A recent European telephone survey of nearly 6,000 respondents with musculoskeletal pain (MP) and almost 1500 primary care physicians revealed that: (a) the majority of the physicians said they were trying to “improve quality of life” and that they were “aware” of the risks of NSAIDs; while (b) ¼ of the respondents had not sought medical help … those who did often waited for several months before doing so … ¾ had constant or daily pain … just over ½ received a prescription for their pain … however, most felt poorly informed. In 5 of the study countries, only ½ of the respondents “were aware of potential side effects.”  Another survey of 662 patients with peripheral neuropathy conducted by the Neuropathy Trust (UK) revealed that up to ¼ of patients waited at least one year before being referred to a specialist, and 2/3 of the sample “felt they were not being kept under review.” In the UK, there are some 1.4 million people with peripheral neuropathy and around ¾ of these are unable to work because of pain. The article concludes that delays “in assessment and diagnosis can be avoided if primary care practitioners are given advice about recognising and treating neuropathic pain.” Dr. Adams Implications:  Possibly in Europe, if primary care physicians are “given advice about recognizing and treating neuropathic pain,” they will translate it into the action that is needed to expertly care for the 1.4 million Brits with neuropathic pain who are unable to work so that they can return to work and the National Health System can realize the cost savings that this change in practice would bring about. However, based on the US experience, changes in how physicians practice is not driven by “advice” but economics. In the US, even mandated continuing medical education (CME) has not achieved this change in practice. Practitioners of all stripes, since the publication of Bonica’s The management of pain in 1953, continue to practice driven mainly by economic self interest rather than “the right thing to do,” what they are “advised to do” nor, most recently, by what their professional organizations mandate them to do in re. CNCP. In one study – Sohn W, Ismail Al, Tellez M (2004). “Efficacy of educational interventions targeting primary care providers’ practice behaviors: an overview of published systematic reviews” J Public Health Dent, 64(3):164-72 – the authors conclude that “evidence from the included systematic reviews showed that formal continuing medical education (CME) and distributing educational materials did not effectively change primary care providers’ behaviors.” Given the history of inaction on CNCP on both side of the Atlantic, the solution is for CNCP patients to take individual action such as: (1) stop patronizing (read “reinforcing”) non-specialists, (2) put together your own multidisciplinary specialty team, (3) pursue a “restoration of maximum functionality” objective, and (4) if you cannot get the rehabilitative support you need from one doctor, fire that doctor and find another one who will. A half century of inaction is an answer:, and that answer is, “No, we’re not going to do anything about chronic intractable pain.” The best thing CNCP patients can do is get the message and start implementing the 4 steps proposed above. If sufficient numbers of CNCP patients do so, consistent withdrawal of reinforcement, science tells us, will predictably extinguish the undesirable behavior.
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